Stent strategies in left main bifurcation lesions: the simpler, the better?

Introduction

Although percutaneous coronary intervention (PCI) for ostial or midshaft lesions in left main (LM) disease has shown similar results as compared with coronary artery bypass grafting (CABG), distal LM bifurcations are associated with an increase in procedural complexity and higher rates of target lesion revascularization. Several studies have investigated the optimal stenting strategy in patients with coronary bifurcation lesions and showed no benefit for systematic two-stent approach in comparison with provisional stenting. This is reflected in the current guidelines that recommend provisional stenting of the side branch as the preferred approach for most bifurcation lesions. However, there is still debate about the optimal strategy according to lesion location.

Objectives

This analysis aimed to compare the clinical outcomes of LM bifurcation PCI using a provisional strategy versus a two-stent strategy.

Methods

Retrospective, observational study including patients submitted to LM bifurcation (Medina 1,1,1) PCI between January 2010 and December 2019. Data was collected from the emergency department and hospitalization registries. Patients were divided according to the stenting approach. We made a global analysis including baseline clinical and angiographic data. The primary endpoint was target lesion failure (TLF), defined as the composite of myocardial infarction, cardiac death, and target lesion revascularization (TLR). Secondary endpoints included the individual components.

Results

A total of 106 patients were included (median age 74 [66–82], 79 (74.5%) males), 57 (53.8%) submitted to provisional stenting and 49 (46.2%) to a two-stent technique. Baseline characteristics were well matched (table 1). The mean SYNTAX score was 29.6±10.0 and LM stenosis grade was ≥70% in all lesions. Median follow-up was 26.6 [12.0–48.6] months. No differences were found regarding the primary endpoint (TLF in provisional stenting was 21.7% vs 21.4%, HR 2.432; 95% confidence interval, 0.472–12.450; p=0.233.). Although target lesion revascularization within the LM complex was numerically higher in the two-stent group (10.2% vs. 3.5%, p=0.245), the opposite was found in cardiac death (provisional group 10.5% vs. 4.3%, p=0.289).

Conclusions

Besides being a “simpler” technique, provisional stenting had no significant differences in outcomes compared to two-stent techniques. Without further evidence, revascularization strategies should primarily rely on operator expertise.

Funding Acknowledgement

Type of funding sources: None.

P3747Does pulmonary vein isolation have similar results for treating AF in Chagas disease?

Background

AF is reported in up to 20% of patients with Chagas, a prevalent disease in Latin-America. PV isolation (PVI) in the cornerstone of AF ablation. However, in Chagas cardiopathy (ChC), microvascular and autonomic abnormalities, atrial fibrosis and sinoatrial dysfunction are possible mechanisms of AF. Therefore, the results of PVI may be different in this subgroup.

Objectives

To describe long-term results of AF ablation in pts with Chagas versus non-Chagas disease (ChC x NonCh) and evaluate risk factors for post-ablation recurrence.

Methods

This is a prospective, single-center study that included pts with nonvalvular AF who underwent PVI between 2013 and 2016. All procedures were guided by eletroanatomic mapping and intracardiac echocardiogram. Categorical variables were analyzed using chi-square test and numerical variables with t-student test. Binary logistic regression was performed to identify independent predictors of recurrence of any sustained atrial tachyarrhythmias.

Results

Ablation was performed in 160 pts (54±15 yo, 59% male): 42 pts with ChC (26%, 62±8 yo) and 118 NonChC (74%, 53±15 yo; p<0,001)). There was no difference in AF type (38x34% paroxysmal, 42x43% persistent, and 19x23% long-term persistent, p=NS) and left atrium diameter (38±5 vs 40±8mm, p=NS). In ChC the mean CHADSVASC score was higher (2.4 vs 1.4, p<0,001) and LVEF was lower (52±18% vs 64±8%, p=0.02). After a follow-up of 31±14 mo and 1.1 ablation per group, recurrence of AF/AT was higher in ChC (33% vs 14%, p=0.03) although more pts with Chagas were on AAD (71 vs 31%, p<0,001). During follow-up, occurrence of embolic events and cardiac or all-cause mortality were not different between groups (0% vs 1.7%, p=NS and 2.4 vs 1.7% p=NS; for ChC vs and NonChC, respectively).

At multivariate analysis, long-term persistent AF, hypertension and Chagas disease (HR= 2.21, 3.36 and 3.16, respectively) were independent predictors of recurrence.

Conclusions

Chagas disease is an independent predictor of recurrence after PVI. Further studies should address which strategy is more appropriate to this group of patients.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Species Identification and Resistance Status of Anopheles gambiae s.l. (Diptera: Culicidae) Mosquitoes in Guinea

Insecticide resistance is one of the primary threats to the recent gains in malaria control. This is especially true in Guinea, where long-lasting insecticidal nets are currently the primary vector control intervention. To better inform the national malaria control program on the current status of insecticide resistance in Guinea, resistance bioassays were conducted, using Anopheles gambiae s.l. Giles, in three sites. Molecular analyses were also done on An. gambiae s.l. to determine the species and find whether the target-site mutations kdr and Ace1R were present. Susceptibility tests revealed resistance to DDT and pyrethroids, although mosquitoes were susceptible to deltamethrin in two of the three sites tested. Mosquitoes were susceptible to bendiocarb, except in Kissidougou, Guinea. The kdr-west mutation was widespread and the frequency was 60% or more in all sites. However, the Ace1R mutation was present in low levels. Insecticide susceptibility should continue to be monitored in Guinea to ensure insecticide-based vector control methods remain effective.

Unilateral nevoid telangiectasia: a rare disease?

Unilateral nevoid telangiectasia is a rare congenital or acquired disorder. The majority of the authors propose that it is probably related to elevated estrogen receptors, although other authors advocate different theories. We report the occurrence of lesions clinically compatible with this diagnosis in a child and two adults. Only one of the patients had a background of estrogen elevation. The other two patients were healthy. We stress the occurrence of this disease in a rare idiopathic form and point out to the relative elevated incidence of it, because the patients discussed in this article were observed for a short period of time.

Our PDT experience in the treatment of non-melanoma skin cancer over the last 7 years

BACKGROUND

Topical photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) was first described by Kennedy et al. in 1990; currently, accumulated evidence shows that topical PDT is effective in the treatment of actinic keratoses, Bowen's disease and superficial basal cell carcinoma, being potentially advantageous where size, anatomical location or number of lesions limit the efficacy and/or the acceptability of conventional therapies. It involves the use of photosensitizing drugs and the administration of an appropriate light source to activate the sensitizing agent, which leads to the production of activated oxygen species for tissue destruction. The topically administered prodrug 5-ALA is converted within cells into the active photosensitizer protoporphyrin IX, via haem cycle, with preferential accumulation in tumour cells.

METHODS

The authors describe their experience with topical PDT, using 20% 5-ALA and two different incoherent light sources, 'Waldman 1200 L' and 'VersaLight', in the treatment of non-melanoma skin cancer and precursor lesions. More than 100 patients were treated since 1997, with up to a 7-year follow-up period.

RESULTS

Cases are illustrated and results are presented and discussed in the light of the relevant Literature.

CONCLUSION

The study suggests that 5-ALA PDT is effective in the treatment of superficial skin cancer and premalignant lesions.

Adenosquamous carcinoma in Barrett's esophagus presenting as pseudoachalasia

A case of pseudoachalasia resulting from adenosquamous carcinoma arising from the mucous epithelium of a Barrett's esophagus is presented. This case represents an unusual combination of Barrett's esophagus giving rise to an esophageal carcinoma with squamous as well as glandular features, rather than the usual adenocarcinoma and pseudoachalasia.

Prolonged ambulatory pH monitoring in patients with persistent gastroesophageal reflux disease symptoms: testing while on therapy identifies the need for more aggressive anti-reflux therapy

Patients with gastroesophageal reflux disease (GERD) who remain symptomatic despite receiving a moderate dose of a proton pump inhibitor need accurate assessment to determine who will respond to high doses of the drug or even need surgery.

AIM

To determine if prolonged ambulatory pH monitoring performed in patients with persistent symptoms potentially due to GERD while on therapy could predict which patients are likely to benefit from more aggressive anti-reflux therapy.

METHODS

Ambulatory pH studies were reviewed for 45 patients with continuing reflux-type symptoms while on 20 mg omeprazole b.i.d. Patients were separated by typical symptoms (heartburn) versus atypical symptoms (chest pain, asthma, hoarseness, cough, throat burning) and for degree of symptom association with episodes of reflux during pH monitoring (symptom index). Control of esophageal acid exposure by omeprazole was defined as distal esophageal pH < 4 < 1.6% total time.

RESULTS

Of these 45 patients, 14 (31%) had acid reflux that was not controlled by omeprazole 20 mg b.i.d. Thirty-six patients had atypical symptoms of GERD, and 10 of these patients had poorly controlled reflux. Of these 10 patients, only one patient responded to omeprazole 20 mg q.i.d. In the other nine patients, omeprazole at the higher dose controlled the reflux (documented by pH monitor), but symptoms persisted with poor association to reflux. Thus, only one out of 36 patients with atypical symptoms had subsequent improvement in symptoms. Nine patients had persistent, typical GERD symptoms, and five of these patients had poorly controlled GER. The three patients with good symptom correlation and poorly controlled reflux all responded to increased omeprazole whereas the two with poor symptom association did not. One patient with good control of reflux but good correlation of the remaining reflux to persistent symptoms also responded symptomatically to 80 mg of omeprazole.

CONCLUSION

By assessing symptom correlation to reflux episodes and control of reflux by therapy, ambulatory pH monitoring performed in patients with persistent symptoms potentially due to reflux while on therapy gives valuable information concerning further treatment strategies.

Evaluation of off-axis projection geometry in dental panoramic radiography

New electronic imaging capabilities afforded by the use of linear charged-couple device arrays allow acquisition of three-dimensional information through simultaneous recordings from multiple sensors situated at different fixed angles. In theory, the resulting data can be processed to yield images tailored to specific diagnostic tasks that can be produced and manipulated on demand after exposure. The first step to determine the practical potential of such a system in panoramic radiography is to demonstrate the degree to which specific changes in projection geometry can be used to improve performance of selected diagnostic tasks of clinical interest in dentistry. Hence, the purpose of this investigation was to explore the potential to reduce proximal overlap that exist in current panoramic radiographs and also to displace the blurred image of the spine from areas of diagnostic interest through the use of off-axis projection geometry of the slit beam of radiation. As the off-axis angulation increased, more embrasures in the different areas of the dental arches of skull specimens were opened; the effects of beam angulation in the number of open embrasures was statistically significant (ANOVA, p < 0.05). A hypothetical multibeam system significantly improved the projection geometry toward the creation of images that contain little, if any, proximal overlap when compared with the conventional bilaterally symmetrical projection geometry system (t test, p < 0.001). At 6 degrees off-axis projection angle, the system was able to clear completely the anterior area from the superimposing shadow of the spinal column. The results show that multibeam alternatives to the single beam projection can significantly improve diagnostic quality in panoramic radiographs.

A case-control study on the association of hepatitis B virus infection and hepatocellular carcinoma in northeast Brazil

Hepatitis B virus (HBV) serological markers were investigated in 40 incident cases of hepatocellular carcinoma (HCC) and in two age and sex matched control groups, comprising 40 patients with other cancers and 80 healthy individuals, resident in Bahia, Brazil. Serologic tests were done by radioimmunoassay. The study observed high proportion of seropositivity to HBsAg (42.5%) and of those presenting HBsAg or antiHBc (65.0%) among HCC cases, higher in men than women and in those aged 17 to 30 years old. HBsAg seropositivity among HCC patients was greater than in the control group with other cancers (7.5%) and in healthy controls (2.5%), corresponding to odds ratio estimates of 15.0 (95% CI 3.29, 68.30) and 33.0 (95% CI 9.13, 119.28), both statistically significant. HBeAg was not observed and antiHBe was present in 41.2% of cases, suggesting the absence of viral replication, possibly with viral DNA integration into the hepatocyte genome. The presence of cirrhosis was associated with HBsAg seropositivity among HCC cases. A history of chronic alcoholism is shown to be more frequently related to those cases with cirrhosis. This study highlights the relevant association between HCC and HBV in Northeast Brazil, particularly for young individuals, and the high risk of development of HCC for HBsAg carriers.

[Forms of hepatic disease in alcoholic patients in Salvador, BA]

This study was carried out to evaluate the relative importance of various patterns in liver in patients followed with chronic ethylism at the Hepatology Unit Care Service of the Hospital Prof. Edgard Santos--University Federal of Bahia, Brazil. Ninety six individuals were submitted to liver biopsy. Of those, 69 (71.9%) presented with alcoholic lesions and 27 (28.1%) had other histologic features of liver disease not commonly related to alcoholism. These data suggested that the presence of other types of liver diseases are prevalent in alcoholic patients in Bahia and showed that, in addition to clinic and laboratorial evaluation, it is essential to perform the histological study to complete the diagnostic of the patients, and detect other liver diseases not associated to alcohol.